根据冠状窦电极走行个体化选择房间隔穿刺时右前斜位透视角度的应用体会

目的总结在行房间隔穿刺时根据冠状窦电极走行特征个体化选择右前斜位透视角度的实际应用体会。方法选择50例因接受房颤导管消融手术而需行房间隔穿刺的患者为研究对象。每例均先经左侧或右侧锁骨下静脉放置冠状窦电极,在后前位透视下,将房间隔穿刺针及长鞘管从上腔静脉回撤至冠状窦口上方1．0～1．5个椎体高度,然后在右前斜位透视下完成穿刺。右前斜位透视角度根据冠状窦电极走行特征选择。记录每例穿刺时的透视角度。结果50例均顺利完成房间隔穿刺,无并发症发生。穿刺时右前斜位透视角度为（35．5±87．21）°,其中多数病例（33例,66％）透视角度为25°～35°。透视角度与左房内径呈弱负相关（P=-0．055,r=-0．27）。结论根据冠状窦电极走行选择房间隔穿刺时的右前斜位透视角度,可以更好地展示房间隔平面,有利于穿刺点准确定位,提高穿刺的成功率及安全性。     

重度二尖瓣狭窄球囊分离术42例分析

目的 探索重度二尖瓣狭窄球囊分离术治疗的新方法.方法 房间隔穿刺点定位,采用吞钡食管左心房压迹定位法,以压迹上下缘的中下1/4水平线为房间隔穿刺高度,与脊柱中右1/4垂线的交点为房间隔穿刺点,穿刺成功率100%.穿刺成功后于右前斜位25°下行直接左心房造影,根据二尖瓣口位置调整二尖瓣探条(stylet),引导Inoue球囊过二尖瓣口,必要时在超声心动图指导下进左心室,选用直径23～28mm球囊扩张.结果 全部患者均成功,跨二尖瓣压差自18～51(34±11)mmHg降至4～9(7±3)mmHg(t=2.623,P<0.01).左心房平均压自20～60(38±13)mmHg,降至6～13(8±3)mmHg,二尖瓣听诊区雷鸣样舒张期杂音明显减轻或消失,效果显著(t=2.714,P<0.01).结论 对于风湿性心脏病重度二尖瓣狭窄,食管左心房压迹定房间隔穿刺点,安全而方便.右前斜位25°下,直接左心房造影显示二尖瓣口,指导Inoue球囊导管进左心室成功率高.     

下腔静脉造影指导犬房间隔穿刺术

目的　介绍下腔静脉造影指示下犬房间隔穿刺术方法。方法　对9只健康杂种犬进行了下腔静脉造影指示下的房间隔穿刺术。全麻下经皮穿刺右侧股静脉,X线投照角度RAO 30°,经Mullins鞘管注射76 %的泛影葡胺2 0mL行下腔静脉造影,分别显示下腔静脉及其开口、右心房影、左心房影和主动脉根部影,将Brockenbrough穿刺针远端弯度的近端塑形增加1个弯度,使穿刺针方向指示器指向3点左右、针尖顶至房间隔进行穿刺。结果　( 1 )下腔静脉造影显示与房间隔穿刺有关的解剖特征为下腔静脉开口位置高,全部在房间隔中上部,使房间隔穿刺点位置也高,加上左心房腔小,穿刺针易穿至左心房顶部;( 2 )下腔静脉造影指导下房间隔穿刺术成功率为1 0 0 % ( 9/ 9) ,心脏压塞1例,经X线和造影剂指示心包穿刺引流术控制。结论　下腔静脉造影指导下的经皮犬房间隔穿刺术简单易行。     

房间隔穿刺点食管左心房压迹定位法--房间隔穿刺定位的新方法

目的探索房间隔穿刺点定位的新方法.方法84例风湿性心脏病(风心病)二尖瓣狭窄患者,按入院先后顺序单纯随机分成研究组和对照组各42例,两组年龄、心脏大小等无显著差异,有可比性.研究组42例采用食管左心房压迹定位法,对照组42例采用Ross改良定位法,房间隔穿刺成功后均行直接左心房造影.结果研究组食管左心房压迹清楚,房间隔穿刺点容易确定,行房间隔穿刺成功率100%.对照组15例左心房轮廓不清,按定位点行房间隔穿刺成功率仅64.29%(27/42).两组有非常显著性差异(x2=18.26,P＜0.001).15例改行食管左心房压迹定位后,均穿刺成功.直接左心房造影显示,左心房大小与食管左心房压迹长度相关性好,成功房间隔穿刺点均在左心房影中下1/3水平线与脊柱中右1/3垂线之交点上.结论食管左心房压迹定房间隔穿刺点,方法准确安全,简单易行.     

三维心腔内超声结合全三维指引下零射线穿刺房间隔的安全性及可行性研究

目的:评估三维心腔内超声(ICE)结合全三维(T3D)指引下零射线穿刺房间隔的安全性及可行性。方法:应用标测导管及消融导管构建右房、上下腔静脉及冠状窦模型，应用ICE构建左房结构。右前斜45°(RAO45°)结合左前斜135°(LAO135°)选取冠状窦口与右肺静脉开口或者右房后缘之间中点为房间隔穿刺点，在ICE结合T3D指导下进行房间隔穿刺。观察此方法房间隔穿刺成功率及并发症情况。结果:45例患者应用此方法进行房间隔穿刺，其中43例患者第1针穿刺成功(95.6%),2例患者穿刺第2针成功。平均房间隔穿刺时间(4.16±2.41) min。所有患者均无房间隔穿刺相关并发症出现。结论:应用ICE结合T3D的方法零射线穿刺房间隔安全有效，并可获得较为理想的房间隔穿刺部位。     

右室间隔部起搏的部位选择与X线影像特点——简单方法确定起搏后QRS波尽可能窄的部位

目的探讨右室间隔部不同部位起搏后QRS波时限与形态,并分析起搏后QRS波较窄处电极的X线影像特点与定位方法;方法将本院近期行右室间隔面起搏50例患者心室电极植入部位在X线后前位结合脊柱影分为高、中(距心影下缘1.5～2个椎体影)、低三部分,右前斜位(RAO)时将心影纵向均分为4区,并分析左前斜位(LAO)下电极的指向,不同部位起搏术中测试参数,起搏后QRS波形态,电轴,时限,术中、术后并发症以及随访中起搏器工作情况;结果所有电极LAO投照时均指向脊柱侧,RAO投照时电极头端位于心影3区(46支)或4区(4支),后前位下中位间隔组起搏后QRS波时限明显窄于高位和低位组(138±21 ms vs 162±20 ms,159±35 ms),电轴也较其他两组更接近于正常(40±35度)(P<0.05),3组术中测试参数与随访结果无差异。结论在间隔面距心影下缘1.5～2个椎体影高度处且RAO时头端位于3区者起搏后QRS波时限较窄,电轴较正常,植入简便安全。     

下腔静脉放置冠状静脉窦电极“转弯处”——一种安全简便的房间隔穿刺新方法

本文介绍一种安全简便的房间隔穿刺新方法。对124例患者进行204次房间隔穿刺术,根据冠状窦电极"转弯处"定位房间隔的下部最低点,在右前斜位(RAO)30°或RAO 45°下这个"转弯处"都可以理解为房间隔下部的最低点。只要充分暴露"转弯处",无论RAO的角度如何,无非是卵圆窝展开面积的大小不同。理解了这一点对于房间隔穿刺尤为关键,这也就是此种方法穿刺快捷简便的重要原因。根据下腔静脉放置冠状窦电极时特征性的定位标志"转弯处",指导房间隔穿刺位置的判定,可以使初学者更加安全快捷地掌握房间隔穿刺术,值得临床推广。     

下腔静脉造影——一种定位房间隔穿刺相关结构的有效方法

目的描述一种用于定位房间隔穿刺关键解剖结构的简单可靠方法。方法在2012年3~11月心房颤动(简称房颤)消融术中,连续3次穿间隔失败的23例患者中应用下腔静脉(IVC)造影指导房间隔穿刺术(TP)。在右前斜45°透视下,将造影管远端置于IVC口下1 cm处注射5~10 ml造影剂。IVC、右房(RA)、右室流入道(RVIT)和右室流出道(RVOT)依次显影。RA,RVIT和RVOT之间围绕的无造影剂充盈的区域是主动脉根部及相邻组织。冠状窦(CS)电极经股静脉置入,其转弯处标志CS口上缘。右前斜45°投照下,合适的房间隔穿刺点(TPS)应在RA的中间、无冠窦的后下方、CS口的后上方。结果 23例均成功完成IVC造影指导下的房间隔穿刺(20例1次穿刺成功,3例2次成功),并达到房颤消融的所有终点。91%(21/23)的患者所有结构清楚显示,能清楚看到所有患者RA下缘、后缘和无冠窦,在2例中RA上缘不能清楚显示。由IVC造影提示的最佳TPS在22例患者中是合适的。在IVC造影图像中,沿无冠窦后缘最头侧与CS口上缘之间连线的中点画一水平线(AE),AE线平分为4段。在87%(20/23)的患者,最佳TPS是在AE线上的左半段。结论 IVC造影能提供关于TPS定位及其周围解剖结构的重要信息,IVC造影确定的TP很适合应用于房颤导管消融术。     

冠状动脉钙化的X线表现及临床意义

冠状动脉粥样硬化继发钙化,以老年人所占比例较高。在影像增强透视下比较容易显示。但其临床意义诸家认识不一。为有助于冠心病的诊断和预后估测,本文复习了冠状动脉钙化的X线表现,以提高对此征象的认识。一、冠状动脉钙化的X线检查和表现Oliver认为常规透视由于荧光屏光亮度低,只能发现较大的冠状动脉钙化,而影像增强透视是最满意的检查方法。Kelley认为心脏透视时应观察后前位、左前斜60°位、左侧位和右前斜45°位。以确     

改良房间隔穿刺术学习曲线研究

目的 评价初学者应用改良的房间隔穿刺术的学习曲线.方法 改良的房间隔穿刺术仅应用冠状静脉窦导管作为解剖标志即可完成房间隔穿刺.选择2011年5月至2011年12月阜外心血管病医院心律失常中心的房颤患者120例.3名既往无房间隔穿刺经验的初学者各接受30例穿刺培训,1名经验丰富的培训者完成30例房间隔穿刺作为对照组.分析下列参数:1针穿刺成功率、总操作时间、透视时间和操作过程中放射剂量.应用曲线拟合统计方法分析学习曲线重要参数(平均初始穿刺时间、平均学习平台穿刺时间和平均学习率).结果 初学者的1针穿刺成功率为82.2％ (74/90),第2针穿刺成功率12.2％(11/90),5例患者穿刺失败.平均初始穿刺时间(4.1±0.8)min,平均学习平台穿刺时间(1.2±0.2)min.穿刺时间平均学习率(25±3)例.初学者房间隔穿刺学习曲线的重要参数可以通过反向拟合曲线统计方法计算得出.结论 对于初学者,改良的房间隔穿刺技术是一项简单、易学、经济和有效的培训和学习方法.基于本研究结果,初学者通过29例房间隔穿刺操作可以通过学习曲线的陡直区域,基本掌握房间隔穿刺技术.     

Fluoroscopic guidance in transseptal catheterization for percutaneous mitral balloon valvotomy

A percutaneous mitral balloon valvotomy (PMBV) was attempted on 190 patients with fluoroscopic guidance of atrial septal puncture for transseptal catheterization; in 3 cases, the procedure could not be performed. The left atrium was always reached on the first attempt, when the relationship of the Brockenbrough needle to the aortic catheter was previously observed in 3 fluoroscopic views: anteroposterior, 45 degrees right anterior oblique, and lateral. The atrial septal puncture site was located immediately below the aortic valve level, probably in the fossa ovalis, for the first 80 patients, and at mid distance between the aortic valve level and the diaphragm for the last 110. Hemodynamic data were similar in both groups. Fluoroscopic guidance for atrial septal puncture seemed capital for patients with scoliosis or in whom a vascular distortion (e.g., advanced pregnancy, right inferior vena cava absence) prevented a perfect parallelism between the needle curve and the needle outer index.     

Atrial morphology in hearts with congenitally corrected transposition of the great arteries: implications for the interventionist

INTRODUCTION: In view of the possible need for septal puncture to ablate left-sided lesions and the occasional difficulty in coronary sinus (CS) cannulation, we investigated relevant anatomic features in the right atrium of hearts with congenitally corrected transposition of the great arteries (ccTGA). METHODS AND RESULTS: Nine hearts with ccTGA and an intact atrial septum and eight weight-matched normal hearts were examined by studying the "septal" aspect of the right atrium with reference to the oval fossa (OF). The anterior margin was arbitrarily measured as the shortest distance from the OF to the superior mitral/tricuspid annulus. The posterior margin was measured from the OF to the posterior-most edge of the right atrial "septal" surface. The total "septal" surface width was measured at the middle of the OF. The stretched OF dimensions and CS isthmus length were noted. Mann-Whitney test was used to compare absolute and indexed dimensions, i.e.. normalized to total width. The posterior margin in hearts with ccTGA was shorter than in controls (6.3+/-2.4 mm vs 11+/-1.9 mm, P < 0.001; normalized margin P = 0.09). The CS isthmus also was significantly shorter (5.3+/-2.7 mm vs 11.4+/-2.2 mm, P < 0.001). In two hearts with ccTGA, the CS opening into the right atrium was on the same side of the eustachian valve as the inferior caval vein. CONCLUSION: The shorter posterior "septal" margin in hearts with ccTGA may increase the risk of exiting the heart while performing septal puncture when pointing the needle posteriorly. The shorter CS isthmus and the abnormal location of the CS opening in some of these hearts are important when contemplating radiofrequency ablation in this area.     

选择性右下肺动脉造影房间隔穿刺定位法

本文就经皮穿刺球囊二尖瓣成形术X光透视下对心房双重影欠佳时，采用手推5～10ml造影剂经右下肺动脉造影法，当造影剂经右下肺静脉流入左心房时，左心房下缘影即可清晰显露，从而方便进行房间隔穿刺定位。临床应用26例，全部成功，无任何并发症。此法简单、安全、易掌握，值得临床推广应用。     

选择性上肺静脉造影显示下肺静脉开口位置的研究

目的探讨心房颤动(简称房颤)射频消融治疗中通过选择性上肺静脉造影显示下肺静脉开口位置的可行性与效果。方法97例房颤患者,取左前斜位(LAO)50°和右前斜位(RAO)50°两个体位进行左上肺静脉造影。取LAO50°及RAO30°两个体位进行右上肺静脉造影。结果97例(100%)均可通过选择性左上肺静脉造影清晰显示左下肺静脉开口的下缘,其中78例(80.4%)可以清晰显示左下肺静脉的开口前缘。79例(81.4%)患者可以清晰显示左下肺静脉开口的后缘。选择性右上肺静脉造影时,86例(88.7%)能够清晰识别右下肺静脉开口下缘,76例(78.4%)能清晰显示右下肺静脉开口前缘,81例(83.5%)能清晰显示右下肺静脉开口后缘。结论选择性上肺静脉造影不仅能够显示上肺静脉的开口位置,而且在大部分患者中亦能较清晰显示下肺静脉的开口解剖。     

Atrial pacing at multiple sites in the Wolff-Parkinson-White syndrome.

Atrial pacing at multiple sites was used in an attempt to predict the site of pre-excitation in 5 patients with Wolff-Parkinson-White syndrome with 5 different anomalous pathway locations (right anterior, right posterior, septal, left posterior, and left lateral). At least 3 atrial pacing sites were tested in each patient. Pacing sites tested included high right atrium, low lateral right atrium, low septal right atrium, proximal coronary sinus, and distal coronary sinus. Atrial stimulation sites with shortest and longest stimulus-delta intervals could be identified in each patient, the shortest stimulus-delta interval in each case ranging from 60 to 80 ms. The difference between the shortest and longest stimulus-delta interval in each case ranged from 60 to 110 ms. It was suggested that the site with the shortest stimulus-delta interval corresponded to a site close to the atrial insertion of the anomalous pathway. This hypothesis was confirmed in all cases (3 with epicardial mapping and 2 with retrograde atrial activation data). In conclusion, atrial pacing at multiple sites is helpful in predicting the site of anterogradely conducting anomalous pathways, and appears particularly useful for differentiation of right posterior, left posterior, and septal pre-excitation.     

Using left atrial esophagus impression after a barium swallow to determine the optimal septal puncture site during percutaneous balloon mitral valvuloplasty

BACKGROUND: Transseptal catheterization is the key to a successful percutaneous balloon mitral valvuloplasty (PBMV). The primary aim of the study was to investigate new methods of transseptal catheterization for PBMV. METHODS: Eighty-four patients with rheumatic mitral stenosis were randomized into two groups for PBMV. In the study group, the left atrial (LA) impression on the esophagus after a barium swallow was used as a reference of LA silhouette to determine the septal puncture site. In the control group, the LA silhouette under a normal fluoroscopic view was used for the determination of septal puncture site. RESULTS: In the study group, the average length of esophagus impression after a barium swallow was similar to the size of the left atrium measured by angiography (43.8+/-0.6 mm versus 44.1+/-0.7 mm, n=42, P>0.05). The success rate of atrial septum puncture in the study and control groups were 100% and 64.3%, respectively (P<0.01). Transseptal catheterization was subsequently achieved using the barium swallow approach in the 15 initially unsuccessful patients from the control group. PBMV was successful in the 84 patients with significant reduction in LA pressure and improvement of clinical symptoms. CONCLUSIONS: Transseptal catheterization in patients undergoing PBMV can be safely and effectively performed using the barium swallow approach.     

Prolapsed left atrium behind the left ventricular posterior wall: Two dimensional echocardiographic and angiographlc features

Left atrial enlargement can usually be detected accurately using M mode echocardiography. However, in the presence of heart disease, asymmetric enlargement may lead to inaccurate assessment of left atrial size and shape. Pericardial effusion can usually be diagnosed on the basis of characteristic M mode echocardiographic findings. However, false positive patterns sometimes occur with the use of this single dimensional technique. Three patients with a greatly enlarged left atrium are described whose M mode echocardiogram suggested significant posterior pericardial fluid accumulation. In each patient, two dimensional echocardiography detected portions of a huge left atrium that prolapsed behind the left ventricular posterior wall and mimicked an isolated posterior pericardial effusion. In one case a right anterior oblique left ventricular cineangiogram suggested the presence of a ventricular septal defect or a false aneurysm of the left ventricle due to the prolapsed left atrium. Because two dimensional echocardiography can provide accurate spatial orientation with visualization of intracardiac structures in relation to one another in real time, it can identify the presence of left atrial prolapse and play an important role in the differential diagnosis of isolated echo-free spaces behind the left ventricle detected with M mode echocardiography.     

Severe cyanosis due to atrial septal defect and an anomalous inferior vena caval valve

Uncomplicated atrial septal defect is often associated with mild arterial desaturation. A case is reported with severe cyanosis and life-threatening hypoxemia due to an atrial septal defect. Cardiac catheterization revealed normal right heart pressures and an atrial septal defect with shunting of inferior vena caval blood into the left atrium. At surgery an anomalous inferior vena caval valve was found directing inferior vena caval blood into the left atrium. The embryologic basis for this association is discussed. The delayed onset of severe cyanosis may have been contributed to by the thoracic scoliosis.     

Short- and long-term dobutamine treatment in chronic ischemic heart failure

This study was undertaken in order to characterize the short-term (1 hour) and long-term (72 hours) effect of dobutamine on hemodynamic and regional ejection fraction parameters measured by radionuclear angiography in patients with chronic congestive heart failure due to coronary artery disease. Baseline hemodynamic and radionuclear parameters were measured and then intravenous dobutamine (8.5 mu/kg/min) was administered. The above parameters were determined again after 1 hour and 72 hours of continuous dobutamine administration. Sixty minutes (short-term) after dobutamine administration heart rate and cardiac index increased significantly (p less than 0.001 for both) and peripheral resistance decreased concomitantly (p less than 0.005). Global left ventricular ejection fraction (LVEF) as measured by multigated equilibrium nuclear angiography (MUGA) increased from 21.8 +/- 10.6% to 25 +/- 13.5 (p less than 0.02). Count-based mean regional ejection fraction in the septal, inferoapical, posterolateral (45 degrees left anterior oblique view) and inferior apical and anterolateral (30 degree right anterior oblique gated first pass) regions increased also. At 72 hours (long-term) after continuous dobutamine infusion, heart rate and cardiac index were still significantly higher and peripheral resistance lower than in the control study. However, global and count-based regional ejection fraction decreased to control values in the right anterior oblique view (first-pass analysis) and the left anterior oblique view (MUGA). Global LVEF measured in the right anterior oblique view by first-pass technique was significantly higher than control in the long-term study (23 +/- 9.7 vs. 27.8 +/- 2.4; p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Atrial septal hematogenous cyst with calcification mimicking myxoma: A rare case

A 61-year-old female presented with right atrial mass during physical examination. Contrast-enhanced left heart echocardiography revealed a mass with the size of 32*23 mm in the right atrium, attached to the atrial septum; there was a certain degree of activity and deformation. MRI showed a mass of about 35*22 mm in the right atrium adjacent to the atrial septum, which was diagnosed with right atrial myxoma. Intraoperative TEE showed that the mass was located in the atrial septum close to the inferior vena cava and spontaneous echo contrast with hyperechoic images within the mass. The lesion was resected under cardiopulmonary bypass. Pathological examination revealed that the filling defect was an atrial septal hematogenous cyst with calcification.